Permission to Treat & General Agreement

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PERMISSION FOR TREATMENT

I; the undersigned, hereby voluntarily consent to medical care/diagnostic treatment and/or minor surgical treatment by Dr. Langer deemed advisable and necessary in the diagnoses and treatment of my condition. I am aware that practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as a result of treatment or examination in the office. I authorize the release of any of my past/current medical records for treatment.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

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AUTHORIZATION and ASSIGNMENT

I request that the payment of authorized Medicare/insurance benefits be made either to me or on my behalf for any services furnished by Dr. Langer. I authorize any holder of medical information about me to release to CMS/insurance carriers and its agents any information needed to determine these benefits or benefits related to services.
I hereby authorize Dr. Langer to furnish information Medicare/insurance carriers concerning my medical condition, illness and treatment to determine the benefits for related services. I hereby authorize (assign) my insurance carrier(s)/Medicare to make payment directly to Dr. Langer for medical/diagnostic, surgical benefits payable for the services rendered. I understand that any unpaid balances not covered by this policy will be payable by me. I understand and agree (regardless of my insurance status), that I am ultimately responsible for the professional services rendered. I understand that I am responsible for any charges incurred in my account and if my account is sent to a collection agency and for any returned checks. I understand that Medicare and/or other insurance carriers do not cover all office services/procedures. I agree to take full responsibility for any unpaid balances and that such payment will be made to this physician’s office for services.
I certify that the information I had given here is true and correct to the best of my knowledge. I will also notify you of any changes in my status or in above information.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Signature:

Date:

PRIVACY NOTICE

I have received a copy of Dr. Langer’s office privacy notice as required by HIPPA.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Signature:

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Witness:

Relationship:

GENERAL PATIENT/PHYSICIAN AGREEMENT

Please read the following paragraphs, initial below each paragraph that you have read, understand, and agree to the same.

CONFIDENTIALITY

In an effort to provide the most efficient and effective healthcare, your treating physician will diagnose your illness according to your complaints, symptoms, test results, and medical history. In order to treat the patient appropriately, the patient understands and authorizes treating physician and/or facility to obtain any and all medical records relating to the patient and to communicate with previous physicians by any method, and/or any physician that can assist with the care of the patient as long as confidentially is kept at the physician level. I have read, understand, and agree with the above.

Patient or Guardian Initials:

Date

FORM COMPLETION AND COPIES POLICY

The ever increasing time and cost burden required to complete the multitude of forms being requested by our patients requires Langer Family Medicine PA to implement the following charge policy for all forms.

Completion of one (1) form page = $25

Completion of two (2) or more form pages = $50 (maximum charge)

Completion of Attending Physician Statement = $50

Copies up to 25 pages $1.00 per page and .25 cents after per page (no maximum)

Forms that will be charged a completion fee include FMLA (Family and Medical Leave Act) forms, Disability forms, Attending Physician Statement and other miscellaneous forms. You will be notified upon the completion of your form(s) and the fee associated with them. The fee will need to be paid before the forms are released.

Patient or Guardian Initials:

Date

NO SHOW FOR A SCHEDULED APPOINTMENT

Langer Family Medicine, PA will call your primary phone 1-2 business days prior to next appointment to confirm your visit date and time. If you are unable to make your appointment and do not contact our office 24 hours in advance to cancel, a $25.00 charge will be posted to your account.

Patient or Guardian Initials:

Date

CONTACT INFORMATION

Email Address:

Cell Phone:

Any additional changes in your personal information:

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Electronic signature

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I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.